Swiss health care system is cost-inefficient!

Complaints Corner
1
I've lived in Switzerland for a bit more than half a year now and generally think this is a great country but now the time has come for my first rant. I think that, while the doctors here in Switzerland are generally very competent, the health care system in general is quite cost-inneficient.

The fact that the system is based on private insurances gives the practioners an incentive to exploit the system simply by performing medical operations, usually tests, that provide no value at all or where the value is so small that it really does not justify the costs.

As an example, my doctors here in Zug recently wanted to send me into a competence center in Zürich university hospital for a consultation. In the competence center they insisted me to stay for the night even though my condition was not acute at all. Their only justification for this was that they wanted me to give a urin sample the following morning. At that point they had also already checked me in as an in-patient and told me that I now had to stay for the night or else my insurance company won't pay for the invoice. So I stayed.

I just received a copy from the invoice that was sent to my insurance company. It totals over 10k CHF, and the biggest contributor to this sum is, suprise suprise, the fact that I stayed overnight. I mean c'mon! In practise my insurance company is now paying thousands of francs from a urin sample and I wasted at least half a day from life!

And this is only an individual example as in general I felt that back here in Zug, and especially there in Zürich, they ran every test they could possibly think of having something to with my condition but I seriously doubt that all of them were actually that necessary. From patient's perspective this was of course great, because it's good to be sure and have as much information as possible, but I'm not sure that this makes that much sense from a systemic perspective.

What would have happened in Finland is that I would have been asked to take a piss into a cup at home and then bring the cup with me to the competence center. I would have had to wait several hours longer before I would have actually met a doctor but after that long wait they would have discharged me the same day to get me out the door as soon as possible. Also, through out the process they would have propably performed only half the amount of tests they did here.

2
Nordic countries and Switzerland are the exact opposite in health and social system. If you liked something in Finnland, be sure you won't have it here... and the other way around.

In the north, one pays taxes. In CH, one pays insurance bills. One way or the other, there is no escape. The wellbeing of the companies seems to be a topic to you, I am less untertained by them I must admit. You are right on one point: everybody is very sharp when in comes to maths... medical institutions like taxpayers.

3
I don't necessarily agee. On the surface it may look like it is cost-inefficient. However when you look at on a macro-economic scale I am convinced that the Swiss system is cheaper over-all for the society.

Take a real case from my family; my son needs to see a ortheopedic doctor once a year. We call usually four months in advance and make the appointment. Once we are there we never have to wait more than 5-10 min to get in to the doctor. We discuss the case, the doctor checks my son and then he sends us down to the xray department. We go down and have the xray and then back up to the doctor. We get called right in to the doctor and then he review the pictures and we agree on strategy for the next year.

All in all it takes us about one hour for examination, xray, diagnosis, strategy. This is something that in a system like the Scandinavian would have taken at least 3 visits to the doctor and probably several reschedulings. Each visit probably requiring at least half day off from work for us.

Tests? Same thing. Yes, they may seem unnecessary but when you view it from the efficency in knowing quickly what you have and what you _don't_ have, I believe that in the long run it is a better stratergy and cheaper.

4
The well-being of insurance companies is not that close to my heart either but where do you think they get the money to pay for those invoices? Yes, from our premiums.

5
It was exactly what I ment, sorry TheFinn, for the elliptic style :-)

Wellbeing of company = Our money.

I am sure you thought right away of (about?) your premium too. I have to pay 5.500 CHF before my insurance company take over. Just a guess, but I don't think I was giving that much in taxes for it in Norway (role of oil money in this equation is unknown to me, though).

6
Sorry. But what happened to you is not normal. I lived Switzerland for 8 years and never once has this happened to any one I know, on this board, nor has anyone ever suggested one stay overnight in the hospital just because of a morning urine test. This is certainly not common practice. I don't know what your condition is so maybe you did need it, what do I know.

What I can say is there are idiots and inefficiencies in every system & country.

Personally, I like the system. I can pick from a wide range of plans. I like and am comfortable with the one I had. It was quite complete and comprehensive with a low deductible even though I don't go the doctor very often. My friend pays top of the line insurance with the equivalent high premiums. She goes to all the doctors she wants, when she wants and it also includes a whole bunch of preventative and slightly alternative treatments. She's happy with it. Then I have other friends who are never sick, never go to the doctor beyond the irregular check up and they pay low premiums and high dedcutible. Ie, you pick & choose your plan.

Let's not even get into the inefficiencies of my plan in Argentina!

7
Personally, I am just grateful that I can afford full health cover...and the medicines and doctors that our family needs...

Plenty of places in the world, health cover is for the rich, and the poor just suffer...

In Australia we paid around 30% taxes, and got free health care, but not quite as perfect, up to date or efficient as Switzerland, and you have to be able to advocate your way through the system if you want free care...otherwise there are lots of ways you can get caught paying for a big proportion yourself. And there is still a gap, and you pay up to $750 per year as a family out of pocket and after that the government will pick up 80% of the 'gap' costs...

Here we pay 20% taxes and another 10% of our income each year in health costs. For us the system is much more 'efficient' in that there is never a queue, appointments are scheduled on time, and we have access to some extremely specialised care (my son sees the top specialist for his condition in the world)...

8
As I find this subject really interesting (comparing different countries’ healthcare) my boyfriend ‘kindly’ broke his collarbone last week so I could have first hand experience of a Swiss hospital..... Apols for length of post – I had a lot of time to think while sitting by his bed......

So I was pondering on what we call ‘effectiveness’ (efficiency/quality/value/good service etc) and what this includes –and this is also one of the big questions for any health economist. Is this individual patient length of life?, what about quality of that life? Or whole system outcomes (eg. national recovery rate from surgery)? Or something which includes the ‘softer’ outcomes that patients want (quick access, parking..... choice etc). I think it’s this last definition that we often appreciate about Switzerland)

Across the whole system Switzerland is expensive (costs are 2nd highest in developed world) and the outcomes are also good – in terms of length of life, morbidity etc. But also costs are going up so hence why changes afoot. It’s also fairly expensive on an individual level- compared on a raw basis with taxes/insurance equivalents elsewhere. (see OECD, Commonwealth Fund for more info).

But I guess that’s all fine if what we get for our money is good: And on an individual patient basis effectiveness is harder to measure as what each person defines as value will probably be a combination of health outcomes (of which little info easily/publicly available for comparison at hospital level)and experience: access, convenience etc. And it seems to me that we all judge this differently based on our homeland experiences (eg in England waiting seems almost normal). So for example as per the OP and with my recent real life case study (and I’m not clinical though I’ve worked in a number of hospitals in UK/US) I think it’s likely my boyfriend would have been in for 1 night in England or the US and not the 2 nights he had in hospital here – and we would have preferred this.

What’s also interesting to me is all the perverse incentives that I’m only just beginning to get my head round – so as your canton pays 1⁄2 inpatient costs then actually the insurance companies are a lot less focused on beating down those costs than they are for ambulatory care (where Drs are under increased pressure to justify their actions and the HMO comes to the fore). And some hospitals (not many yet from what I hear) are preparing for introduction next year of a new coding/payment system based on the German system which is also now altering how they work. This means some work will be ‘underfunded’ and some will be ‘overfunded’ –it’s clear what any commercially minded organisation will do...... (or as in England they just fudge the coding.......)

Re your point Tilia whilst not waiting is clearly amazing for the patient, to enable this in all urgent care settings you have to build a degree of additional capacity into your workforce and resources – which we all pay indirectly for in our premiums (or our employers do). So on an academic basis you’re right, on a macro level the system is expensive (comparatively) but there’s good outcomes – the question is I guess whether this is good ‘value’ (or as per the title - efficient) - ie could the system get as good/almost as good outcomes with lower costs. And with hospitals as the driver of the greatest % of costs it will be what they do (or how HMOs and insurers gatekeep/control this activity) that will drive changes.

The last point is the costs of ‘administering’ the system. Yes we’re paying for the profits of the insurance companies but we’re also paying for the running costs of them (and a degree of duplication/lack of economies of scale with so many small orgs). During the last UK election campaign much political capital was made of the need to reduce numbers of ‘bureaucrats’, when insurance based systems naturally build in masses more admin to support billing (England at 4%ish, the US at nearly 20% of all healthcosts – and I guess, although I don’t know for sure, that Switzerland is at the higher end of this). Conversely and nonsensically this rarely gets the same coverage in US healthcare debate.

All very interesting (at least to me) – more so with the disaster that England heading towards with the coalition government’s plans..... I almost can’t bring myself to hear any more about what’s happening there........

Thoughts??????

9
I do not like this system. I a few not so well-off Swiss folks who have the highest franchise and neither they nor their children go to see a doctor because they can hardly afford it. Their foreign spouses see their doctors in their home countries on the home visits.

The franchise method is really a way of pushing the poorer guys into not doing any prophylactic check-ups for decades. In the short term they subsidy the other who can afford lower franchise and visit a doctor more frequently.

Why not have higher deductible instead of franchise? Then going once a year to a doctor and doing some tests wouldn't break a bank.

10
While my experience with hospital care and insurance here in Switzerland hasn't been great, I wouldn't go so far as to condemn the whole system. When it is good, it's very very good, and when it is bad it's horrid. Which is pretty much the same as in many countries.

I've found that one has to ask questions, one has to be one's own advocate. Just as in many other countries. However, the magic phrase 'I am paying for treatment myself' seems to make health care providers far more open to discussion and willing to look for more cost-effective options.

Amazing that several tests were deemed unnecessary, procedures suddenly could be done outpatient rather than in hospital, once the doctor realized that it came out of my own pocket.

11
I like the Swiss system better. So clearly my view is prejudiced.

We pay more than we did in the US, although it's just so much more convenient here on so many levels. And the care I have received here is simply better. In terms of outcomes, I can't tell you that I'll live longer, but I have a chronic condition that wasn't effectively treated in the US and is under control here. I am more active and healthier than I was in the US. My doctor does spend more time with me, and we do pay for it, and I think he is more thorough. For example, my physician in the US didn't want to put me on a particular medication that was more effective because of a possible side effect. It was as if she didn't even bother to try. My physician here suggested that we try the medication, but I could stop it if the side effect appeared. Well, it never did. A small thing, but I find office support staff here to be much nicer than in the US.

And, so far at least (and we've had the same insurer for the last 3.5 years), we've not had the aggrivation and micromanagement that we've experienced with US insurers. For example, my physician does not have to justify to a high school graduate clerical gate keeper working on for a prescription management firm that he wants to give me X drug. And I don't feel that I've had excessive testing. Actually quite the contrary. Just a blood test once a year. A mammogram yearly (it would be every other year, but I am close to the age my mother was when her breast cancer was diagnosed).

Quality of generic drugs is an issue in the US - many generics are made by a wide range of firms, the efficacy of these drugs often varies. Here I think that generics come largely from either Sandoz or Mepha - I suspect there might be better quality control

How do we evaluate the quality of health care? Life expectancy is one thing. I also see a lot of fairly active older people and so I wonder how we compare quality of life between say, Switzerland and the US. To me, it's not the life expectancy per se, but it's the time spent living reasonably independently. I know nothing about the UK system. But I do pay more for choice and for some autonomy. And I pay for the smallest franchise. I realize that not everyone can do this.

If coding systems are to be implemented here, that will be interesting. I'm familiar again with the US system, and know that many doctors, etc, simply find ways to circumvent coding.

I do think Switzerland may need to achieve economies of scale in terms of insurers....but that may need to be done at a national rather than a cantonal level.

It's a balance between cost effectiveness, care and patient satisfaction. Also what works in the UK, Finland and other countries may not work within Switzerland because whatever happens, changes need to fit within the country's governance and philosophy. It's hard to implement new plans... that doesn't mean change is not required, however.

12
In the original post I did not say that things are black and white and that the Scandinavian system is better than the Swiss system (believe me, I know that it has problems as well). I also did not say that the Swiss system is inefficient in terms of results . On the contrary, I feel that the care I have received here has been extremely good, I'm very grateful of it, and I also would say that in general the Swiss health care professionals are very competent.

What I did say, however, is that the system is innefficient in terms of costs . My analogies usually fail but I would still compare the Swiss health care system to Apple iPhone. While the iPhone is very usable, stylish and of great quality, at the same time it is also extremely expensive when compared other products that basically do the same thing.

The reason for this cost-innefficiency is in the system itself. As I said in my original post, the system gives the practioners a financial incentive to do as much as possible not as much as is needed . And, it is 100% sure that every doctor in this world will act according to this incentive if he thinks that he can get away with it.

What annoys me in all this is that at the same time the doctor's are total hypocrites when it comes to discussing the costs. When I for example wanted to discuss costs with my own doctor he did his best to avoid the subject but when I didn't drop the subject he got offended and complained how nowadays everyone wants to talk about money. So in practise he would have just wanted me to keep my mouth shut and write him an open cheque!

Also, some practices may also have a financial pressure for performing operations that are not entirely justified, because in my experience many doctors (specialists especially) really don't have that much customers, and are not that busy, as they would like us to think. I can always get my appointments on a day's notice (even without an emergency) and I rarely see other patients at the practices I visit.

But, I've also understood that the Swiss are ok with paying a high premium for high quality.

13
It's up to us not to encourage this sort of thing. If our doctors won't discuss costs/prices or a health matters, test results, or don't understand we want to say in the hospital when we feel it's not necessary, etc, etc. it is up to all of us to change doctors and to tell them why.

I guess it's easier said than done as I've never felt my care was out of my control. So I don't know for sure what I would do in the situation.

But we can try.

14
[QUOTE=The Finn;1045022

The reason for this cost-innefficiency is in the system itself. As I said in my original post, the system gives the practioners a financial incentive to do [I]as much as possible[/I] not as much as is needed . And, it is 100% sure that every doctor in this world will act according to this incentive if he thinks that he can get away with it. QUOTE]

- Absolutely IMO (I'm Swiss)! But in the Swiss health-care system, we, the patients/clients are a part of the problem, as we are one the players (cantons+hospitals+doctors/specialists+pharma+patients) in the system. So when I go to whatever doctor or specialist I make it clear right from the begining that I'm interested in what is needed and I ask for generics whenever possible. Other people feel better with what we call here " comfort health-care" or health whatever it costs and many people are ready to pay high price for that (I'm not saying its your case!). As someone points out, we have to be our own advocate here.

Tervetuola Sveitsissa!

15
The Swiss system compares very well with the UK in my experience

see this account for example

http://fabooks.wordpress.com/2011/05...ap-not-on-top/

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Yes, as a Swiss friend of mine (and a doctor) admitted to me, the Swiss system does tempt doctors into making extra little tests as they make money from them. Additionally, those people who can afford the highest premium tend to then go to the doctor for every little thing. I know a friend who went to the doctor, who had made an appointment for him which was 30 min long, then they were done after 15 min, and they simply chatted for the rest of the time because the doctor knew the insurance would pay. The result? The premiums are becoming higher and higher, and the people who can hardly afford the most basic of covers are struggling more.

Where I come from, a doctor does not charge per minute, but per visit (unless he has to run some special tests apart from the consultation), which means that it's in his best interest to check you quickly, so as to have more time for more patients (Im talking about simple, GP cases here). In the end, the doctor finds out what's wrong with you without a million tests and you're soon on the road to recovery. Here, for every little think I find that the visit drags for 20 minutes as the doctor checks this and that and bla bla bla, and askes for another visit after a few days. Specialists use the same system, though of course the price per visit is a bit higher.

17
it is absolutely different cause it is not possible to compare a system based on privte insurance and public insurance. For suer a public system warranty the same level of care for everybody while the private one (as it its in switzerland) make difference for peole with more money!!!!

18
Unless your poor of course. In which case the Swiss system is terrible. Morally it is miles inferior to the nhs.

19
I wouldn't mind the expensive insurance system if the quality was accordingly...sorry but you definitely not get what you're paying for...

20
Which is why there are government subsidies for the poor.